Clinical Endoscopy

Review

Management of complications related to colorectal endoscopic submucosal dissection: Tae-Geun Gweon, Dong-Hoon Yang; Clin Endosc 2023;56(4):423-432. Published online July 27, 2023; DOI: https://doi.org/10.5946/ce.2023.104

Compared to endoscopic mucosal resection (EMR), colonoscopic endoscopic submucosal dissection (C-ESD) has the advantages of higher en bloc resection rates and lower recurrence rates of colorectal neoplasms. Therefore, C-ESD is considered an effective treatment method for laterally spread tumors and early colorectal cancer. However, C-ESD is technically more difficult and requires a longer procedure time than EMR. In addition to therapeutic efficacy and procedural difficulty, safety concerns should always be considered when performing C-ESD in clinical practice. Bleeding and perforation are the main adverse events associated with C-ESD and can occur during C-ESD or after the completion of the procedure. Most bleeding associated with C-ESD can be managed endoscopically, even if it occurs during or after the procedure. More recently, most perforations identified during C-ESD can also be managed endoscopically, unless the mural defect is too large to be sutured with endoscopic devices or the patient is hemodynamically unstable. Delayed perforations are quite rare, but they require surgical treatment more frequently than endoscopically identified intraprocedural perforations or radiologically identified immediate postprocedural perforations. Post-ESD coagulation syndrome is a relatively underestimated adverse event, which can mimic localized peritonitis from perforation. Here, we classify and characterize the complications associated with C-ESD and recommend management options for them.

Citations

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Risk Factors, Clinical Course, and Management of Delayed Perforation After Colorectal Endoscopic Submucosal Dissection: A Large-Scale Multicenter Study
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American Journal of Gastroenterology.2024;[Epub] CrossRef

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Case Reports

Endoscopic Treatment of Iatrogenic Perforation of Sigmoid Diverticulum: A Case Report of Multidisciplinary Management: Giacomo Emanuele Maria Rizzo, Giuseppina Ferro, Giovanna Rizzo, Giovanni Di Carlo, Alessandro Cantone, Gaetano Giuseppe Di Vita, Carmelo Sciumè; Clin Endosc 2022;55(2):292-296. Published online June 7, 2021; DOI: https://doi.org/10.5946/ce.2021.005

Abstract PDF PubReader ePub: Iatrogenic perforations are severe complications of gastrointestinal endoscopy; therefore, their management should be adequately planned. A 77-year-old man with a history of diverticulosis underwent a colonoscopy for anemia. During the procedure, an iatrogenic perforation occurred suddenly in the sigmoid colon, near a severe angle among the numerous diverticula. Through-the-scope clips were immediately applied to treat it and close mucosal edges. Laboratory tests showed increased levels of inflammation and infection, and although there were no complaints of abdominal pain, the patient had an extremely distended abdomen. A multidisciplinary board began management based on a conservative approach. Pneumoperitoneum was treated with computed tomography-assisted drainage. After 72 hours, his intestinal canalization and laboratory tests were normal. Though this adverse event is rare, a multidisciplinary board should be promptly gathered upon occurrence, even if the patient appears clinically stable, to consider a conservative approach and avoid surgical treatment.

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Intestinal Perforation Caused by Lumboperitoneal Shunt Insertion Repaired with an Over-the-Scope Clip: Naoki Ishizuka, Eiji Komatsu; Clin Endosc 2022;55(1):146-149. Published online March 3, 2021; DOI: https://doi.org/10.5946/ce.2020.293

Abstract PDF PubReader ePub

Lumboperitoneal or ventriculoperitoneal shunt insertion is a standard therapy for hydrocephalus that diverts cerebrospinal fluid from the subarachnoid space into the peritoneal cavity. Gastrointestinal perforations due to this procedure occur rarely; however, accepted treatment strategies have not yet been established. Hence, the most common treatment approaches are open surgery or spontaneous closure without endoscopy. We report the case of a small intestinal perforation in a 73-year-old-woman that occurred after the insertion of a lumboperitoneal shunt. A positive cerebrospinal fluid culture and high cerebrospinal fluid white blood cell count indicated a retrograde bacterial infection, and computed tomography revealed that the peritoneal tip of the shunt catheter was located in the lumen of the gastrointestinal tract. We repaired the perforation endoscopically using an over-the-scope clip, and the patient’s recovery was uneventful. Use of an over-the-scope clip could be an effective and minimally invasive treatment for intestinal perforations caused by lumboperitoneal or ventriculoperitoneal shunt insertion.

Citations

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Progress in Surgical Treatment of Traffic Hydrocephalus
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1 Crossref

Focused Review Series: Endoscopic Submucosal Dissection for Colorectal Tumors

Management of Complications of Colorectal Submucosal Dissection: Eun Ran Kim, Dong Kyung Chang; Clin Endosc 2019;52(2):114-119. Published online March 29, 2019; DOI: https://doi.org/10.5946/ce.2019.063

Abstract PDF PubReader ePub

Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of superficial gastrointestinal neoplasm. Compared with endoscopic mucosal resection (EMR), ESD has several benefits, which include resectability of various difficult lesion, accurate histologic assessment of specimen, and lower recurrence rate. However, the risk of procedure- related complications is higher with ESD than with EMR. Moreover, because the colon has a thin wall and limited endoscopic maneuverability, ESD is considered a more challenging and risky procedure when performed in the colon than in the stomach. ESD-related complications are more likely to occur. The significant complications associated with ESD are bleeding, perforation, coagulation syndrome and stenosis, most of which can be treated and prevented by endoscopic intervention and preparation. Therefore, it is important to know how to occur and manage the ESD related complication.

Citations

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Management of complications related to colorectal endoscopic submucosal dissection
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Original Article

Angular Positioning of Stent Increases Bowel Perforation after Self-Expandable Metal Stent Placement for Malignant Colorectal Obstruction: Jeong Guil Lee, Kwang Ho Yoo, Chang-Il Kwon, Kwang Hyun Ko, Sung Pyo Hong; Clin Endosc 2013;46(4):384-389. Published online July 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.4.384

Abstract PDF PubReader ePub

Background/Aims

Some factors like stent wires, balloon dilatation and use of guide wires seems to increase perforation after self-expandable metal stent (SEMS) placement, but few studies mentioned about the relationship between angulation of malignant stricture and perforation. The present study aimed to confirm that more angular positioning of stents increases perforation.

Methods

This study was conducted with retrospectively evaluation at Digestive Disease Center, CHA Bundang Medical Center, CHA University. Between January 2002 and August 2011, SEMS was inserted in 130 patients with malignant colorectal obstruction. We studied the difference in the angle of stenosis between perforation and non-perforation groups using fluorography images.

Results

SEMS insertion was performed in 130 cases of obstruction due to colon cancer. Perforation occurred in eight patients (6.2%) of them. Thirteen cases were excluded from the analysis due to poor fluoroscopic images. Among the eight patients with perforation, the mean stenosis angle was 109.9° compared to 153.1° in the nonperforation group, indicating that the angle was more acute in the perforation group (p=0.016).

Conclusions

This study shows that more angular positioning of stent increases bowel perforation after SEMS placement for malignant colorectal obstruction.

Citations

Citations to this article as recorded by

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Case Reports

A Bowel Perforation That Developed during the Transanal Extraction of a Large Rectal Foreign Body: Keun-Suk Yang, M.D., Joung-Ho Han, M.D.^*, Sunyoung Kim, M.D., Woo Hyung Choi, M.D., Hong-Soon Jung, M.D., Eun Chung, M.D., HyenJeong Jeon, M.D.^* and Seijin Youn, M.D.^*; Korean J Gastrointest Endosc 2011;42(6):406-409. Published online May 25, 2011

Abstract PDF: Rectal foreign bodies are rare clinical problem in South Korea. Although many foreign bodies can be extracted safely using endoscopic procedures, some patients require surgery. Here we describe the case of a 35-year-old male who presented with a rectosigmoid foreign body, a large carrot measuring 28×7 cm. Sigmoidoscopy revealed a carrot in the upper rectum extending to the sigmoid colon. Endoscopic removal failed. The surgeon unsuccessfully attempted to extract the carrot using various tools without spinal anesthesia. During the extraction attempt, the patient complained of sudden abdominal pain, and a simple x-ray revealed pneumoperitoneum. An emergency colotomy and removal of the foreign body was performed, followed by primary repair of the perforation and a colostomy. Three months later, the colostomy was repaired.

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A Primary Repair with Hemoclips and Fibrin Glue Injection in Biliary Stent Induced Duodenal Perforation: Ki Won Kim, M.D., Tae Hoon Lee, M.D., Sang-Heum Park, M.D., Bum Suk Son, M.D., Sae Hwan Lee, M.D., Suck-Ho Lee, M.D., Il-Kwun Chung, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2011;42(6):437-441. Published online May 25, 2011

Abstract PDF: Duodenal perforations caused by biliary prostheses are uncommon, but they are potentially life threatening and require immediate treatment. Here we describe an unusual case of duodenal perforation induced by a plastic biliary stent. It masqueraded as a case of cholecystitis and combined systemic upset with a localized peritonitis and fever. Primary endoscopic closure by hemoclips was difficult due to the position of the lateral wall and the complexity of aligning the perforation with the endoscope. To approximate the perforated hole and adherent hemoclips, glue injection and sprayings were successfully performed under cap-fitted endoscopy. The patient recovered without additional complications.

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A Case of a Successful Band Ligation of a Colonic Perforation during Diagnostic Colonoscopy: Heon Nam Lee, M.D., Eui Joo Kim, M.D., Sung Keun Park, M.D., Mi Ryoung Seo, M.D., Jong Joon Lee, M.D., Young Jun Lee, M.D., Kyong Yong Oh, M.D. and Dong Gun Park, M.D.; Korean J Gastrointest Endosc 2010;41(3):176-179. Published online September 30, 2010

Abstract PDF: Colonoscopy is a relatively safe tool for diagnosis and treatment of colorectal disease. But colonic perforation during colonoscopy is a severe complication and sometimes becomes a life-threatening condition. It occurs with a frequency of 0.07% among patients having diagnostic colonoscopy and in up to 0.40% of patients having therapeutic colonoscopy. In these cases, surgical treatment is needed but endoscopic repair and conservative management could reduce the need for immediate operations. Endoscopic clipping has been the principal method for non-operative treatment of iatrogenic colonic perforation, but it has important limitations. One of them is that it is technically difficult to clip when the angle of approach is tangential. Here we report a case of an iatrogenic colonic perforation treated with endoscopic band ligation rather than endoscopic clipping, because of approach difficulties. (Korean J Gastrointest Endosc 2010;41:176-179)

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A Case of Successful Clipping of a Colonic Perforation during Diagnostic Colonoscopy: Soon Ae Kim, M.D., Jae Hak Kim, M.D., Jin Ho Lee, M.D. and Chang Heon Yang, M.D.; Korean J Gastrointest Endosc 2009;38(6):348-351. Published online June 30, 2009

Abstract PDF: The use of colonoscopy is important to prevent colon cancer. Despite the safety of the colonoscopy procedure, the most common complication of a colonoscopy is perforation, which occurs with a rate of approximately 0.3% during diagnostic colonoscopy and occurs with a rate of approximately 1.1% with the use of therapeutic colonoscopy. Surgery is the treatment of choice for most cases of colonic perforation. With the development of endoscopic devices and techniques, conservative treatment of colonic perforation has been reported by the use of endoscopic clipping. We report here a patient with iatrogenic perforation of the sigmoid colon that was caused by diagnostic colonoscopy. The perforation presented as pneumoretroperitoneum, which was successfully treated with endoscopic clipping. (Korean J Gastrointest Endosc 2009;38:348-351)

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A Case of Peripheral T-cell Lymphoma Presenting with Small Bowel Perforation: Se Won Kim, M.D., Yun Jeong Lim, M.D., Hyoung Woo Kim, M.D., Do Yeun Kim, M.D., Chang-Hun Yang, M.D., Jin Ho Lee, M.D., Hong-Yong Kim, M.D.*, Eo-Jin Kim, M.D.^†and Yong Seok Lee, M.D.^‡; Korean J Gastrointest Endosc 2008;37(1):40-44. Published online July 30, 2008

Abstract PDF: Malignant lymphoma of the gastrointestinal tract is a rare lesion that comprises 1∼4% of all the malignant neoplasms of the gastrointestinal tract. The incidence of intestinal T-cell lymphoma is much lower than that of the B-cell type. Intestinal T-cell lymphoma can sometimes carry a very poor prognosis because these patients are often diagnosed at advanced stages. These patients mostly present with nonspecific symptoms such as weight loss, abdominal pain or diarrhea and more frequently with features of small bowel obstruction or perforation. We report here on a case of a malignant small intestinal T-cell lymphoma that presented with perforation. A 51-year-old female had emergency operation because of small bowel perforation and she was diagnosed withperipheral T-cell lymphoma on the post-operative pathologic report. (Korean J Gastrointest Endosc 2008;37:40-44)

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Ileal Perforation due to Cytomegalovirus Enteritis in a Patient with Acquired Immune Deficiency Syndrome: Yeon Soo Kim, M.D., Won Seok Heo, M.D., Kyung Hoon Chae, M.D., Youn Se Gang, M.D., Jae Hoon Jung, M.D., Ki O Park, M.D., Jae Kyu Seong, M.D., Yeon Sook Kim, M.D., Hyun Yong Jeong, M.D. and Geu Sang Song, M.D.*; Korean J Gastrointest Endosc 2005;30(4):217-221. Published online April 30, 2005

Abstract PDF: Cytomegalovirus (CMV) infection is one of important opportunistic infections and cause significant morbidity and mortality in immunocompromised patients. The colon, stomach, and esophagus are the organs frequently involved with CMV infection. CMV enteritis makes up less than 10% of the CMV gastroenteritis cases, usually presents with diarrhea, bleeding and perforation. Several reports have described patients with acquired immune deficiency syndrome (AIDS) in whom CMV enterocolitis were complicated by ileal perforation, but have been rarely reported in Korea. We report a case of multiple ileal perforation associated with CMV enteritis in 67 years old man who was diagnosed as AIDS later. He complained of hematochezia and abdominal pain. During emergency operation, multiple perforated lesions were seen at the distal ileum above ileocecal valve. Colonoscopic examination revealed multiple shallow aphthoid ulcers at descending colon. CMV enteritis and colitis were diagnosed by microscopic findings of both surgical and endoscopic specimens. He was recovered by antiviral therapy with ganciclovir. (Korean J Gastrointest Endosc 2005;30:217⁣221)

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A Case of Sigmoid Colonic Perforation due to Migration of a Plastic Stent for Endoscopic Retrograde Biliary Drainage: Hyun Sweung Jeong, M.D., Sang Jong Park, M.D., IL Dong Kim, M.D.*, Sang Bae Lee, M.D., Jin Kwang Lee, M.D. and Hoi Jin Kim, M.D.; Korean J Gastrointest Endosc 2004;28(3):156-160. Published online March 31, 2004

Abstract PDF: Placement of an endoprosthesis for billiary obstruction has been advocated as an effective alternative for internal- external drainage catheters or surgical procedure. Endoscopic retrograde biliary drainage (ERBD) is a method of transpapillary insertion and placement of drainage tube in the billiary tree under the direct view of endoscope. Early complications following ERBD that develop within 4 weeks include obstruction of the stent, cholangitis, hemorrhage, acute pancreatitis, and bile duct or duodenal perforation. Late complications include obstruction of the stent and cholangitis, migration of the stent, and intestinal perforation. We expierenced a case of sigmoid colonic perforation following ERBD in a patient with multiple biliary tract stone and cholangitis. Thus we report this case with a brief review of the literature. (Korean J Gastrointest Endosc 2004;28:156⁣160)

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